IN THE COURT OF COMMON PLEAS OF 
 _____________________________ COUNTY, PENNSYLVANIA 
ORPHANS’ COURT DIVISION 

(FAMILY COURT DIVISION in Philadelphia County) 

IN RE: ADOPTION OF ________________ 

 (initials only) 

ADOPTION NO. _____________________ 

PETITION FOR ADOPTION OF A FOREIGN BORN CHILD 

To the Honorable, the Judge of said Court: 

The Petition of__________________________________________________ under 

(Name(s) of Adopting Parent(s)) 

23 Pa. C.S. §§ 2701 and 2908 respectfully states that: 

1.
At least one of the Petitioners filing this Petition is a resident of the
Commonwealth of Pennsylvania and has resided in this Commonwealth since
__________________________________________________________________

 (Provide at least month and year) 

2.
No other court in this Commonwealth or in any other state has reviewed,
registered, finalized or otherwise assumed jurisdiction over the adoption of this child,
except as follows:  ___________________________________________________

(Provide name of court, county and state)  

Explain the proceeding previously initiated and the resulting decision from the court: 
(Attach all court decrees). 

3.

Petitioner(s) desire(s) to adopt this child known as

(Name of child as written on Foreign Decree) 

and intend(s) that such child shall be treated as one of (his/her/their) heirs and 
hereby declare(s) that (he/she/they) will perform all the duties of parent(s) to him/
her. 

The child has entered the United States pursuant to a United States visa.  A

4.
true and correct copy of the United States Visa is attached as an exhibit to this
Petition.  The United States Visa was issued as an:

(please check one)  

IR-2  

IR-3  

IH-3  

IR-4  

 IH-4 

5.

a) The child’s full name as shown on the United States visa is

Form A-09 Rev. 07/01/22

1b) The full birth name of the child as listed on the foreign birth certificate (if
available) is
______________________________________________________________

c) The full name of the child as it appears on the foreign decree is
______________________________________________________________

d) The full name of the child as he/she is to be known from this time forward is
______________________________________________________________

The child has resided with Petitioner(s) for the following length of time ______
______________________________________________________________

Information concerning the Petitioner(s), the adopting parent(s), is as follows:
a) Adopting Parent #1:

6.

7.

1) Full name
2) Residence

3) Marital status
4) Age
5) Occupation
6) Religious affiliation
7) Racial background
8) Relationship to adoptee by blood or marriage, if any
9) Daytime telephone no.

b) Adopting Parent #2:

1) Full name
2) Residence

3) Marital status
4) Age
5) Occupation
6) Religious affiliation
7) Racial background
8) Relationship to adoptee by blood or marriage, if any
9) Daytime telephone no.

8.

The following reports, as applicable, have been completed as of the dates set
forth below.  A true and correct copy of each of these reports is attached as
an exhibit to this Petition.

a) Report of Intermediary described in 23 Pa. C.S. § 2533

b) Home Study and/or Preplacement Reports described in 23 Pa. C.S. § 2530

Completion Date:

Completion Date:

c) Investigation Reports described in 23 Pa. C.S. § 2535

Completion Date:

d) Postplacement Reports, if any
Completion Date (if applicable):

Form A-09 Rev. 07/01/22

29. Information concerning the intermediary agency, if any is as follows:

If there is no Report of an Intermediary, the following information is

10.
being provided by the Petitioner(s) as to the adoptee or adopted child:

Name of agency 
Address 

Telephone no. 
County where office is located 

a) Sex
b) Racial background
c) Age
d) Birth date
e) Birthplace
f) Places of residence since birth

g) Religious affiliation
h) A full statement of the value of all property owned or possessed by the

child, if any

why not

i) State whether medical history information was obtained, and if not, explain

If there is no Report of an Intermediary, and the adoptee pr adopted child is

11.
under 18 years of age, provide the following information as to the birth mother, if
known:

a) Name
b) Residence or last known address

c) Racial background
d) Age
e) Marital status as of the time of the birth of child
f) Marital status during one year prior to birth of child
g) Religious affiliation
h) Birth mother’s parental rights were terminated by decree of

 dated 

Form A-09 Rev. 07/01/22

3If there is no Report of an Intermediary, and the adoptee or adopted child is

12.
under 18 years of age, provide the following information as to the birth father, if
known:

a) Name
b) Residence or last known address

c) Racial background
d) Age
e) Marital status as of the time of the birth of child
f) Marital status during one year prior to birth of child
g) Religious affiliation
h) Birth father’s parental rights were terminated by decree of

dated

If there is no Report of an Intermediary, attach a copy of the birth certificate,

13.
with an English translation for those birth certificates not in English, certified by a
translator to be true and correct.  .  If no birth certificate or other birth identification
issued by the country of birth can be obtained, a statement of the reason and a
detailed explanation of the efforts made to obtain the certificate are required and
attached as an exhibit to this Petition.

If there is no Report of an Intermediary, attach copies of any foreign decrees

14.
and/or documents concerning this adoption, including any decree terminating the
parental rights of birth mother and/or birth father, if needed, with an English translation
for those decrees and/or documents not in English, certified by a translator to be true
and correct translations of the foreign decrees and/or documents.

15.
If there is no Report of an Intermediary, attach all consents required by Section
2711 of the Adoption Code, 23 Pa. C.S. § 2711.  If consents are not required, explain:

Attach Pennsylvania Department of Health, Division of Vital Records Form No.

16.
HD01273F, Certificate of Adoption of a Foreign-Born Child with Parts 1 and 2 (and
Part 3, if applicable) completed.

Attach Pennsylvania Department of Health, Division of Vital Records Form No.

17.
HD01275F, Statement of Citizenship and Residency.

Attach U.S. Government Form N-560, Certificate of Citizenship, and/or a copy

18.
of the child’s United States passport, if either or both documents are available.

It is the desire of the Petitioner(s) to have a parent and child relationship

19.
established between the Petitioner(s) and the adopted child.

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4WHEREFORE, Petitioner(s) pray your Honorable Court to enter a Final 
Decree that the child proposed to be adopted shall have all the rights of a child and 
heir of Petitioner(s) and Petitioner(s) shall be subject to the duties as parents of such 
child, and that the child’s name shall henceforth be  

___________________________________________________________________ 

DATE:__________________ 

______________________________ 
1
Signature of Adopting Parent

_____________________________ 
Signature of Adopting Parent 

____________________________________________ 
____________________________________________ 
____________________________________________ 
____________________________________________ 
(If represented, counsel’s name, address, and telephone number) 

1

When there are two adopting parents, both must sign.

Form A-09 Rev. 07/01/22

5VERIFICATION TO PETITION FOR ADOPTION OF A FOREIGN BORN CHILD 

I/We, ______________________, verify that I/we are the Petitioner(s) named in the 

foregoing Petition and that the facts set forth therein are true and correct to the best 

of my/our knowledge, information and belief.  I/We further verify that all documents 

attached to this Petition are true and correct copies of the originals.  I/We understand 

that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 

relating to unsworn falsification to authorities. 

DATE: ____________________ 

___________________________ 
Signature of Adopting Parent 

___________________________ 
Signature of Adopting Parent 

Form A-09 Rev. 07/01/22

6